* = Required Information

Application For Employment
Names *
Present Address *
How Long
 Social Security No.
Telephone
 Alternate Number
Position Applied for (Be Specific) *
How many hours can you work weekly?
 Can you work nights?
Employment Desired
Full-Time Only Part-Time Only Full or Part-Time
When available for work?
TYPE OF SCHOOL NAME OF SCHOOL LOCATION NO. OF YEARS COMPLETED MAJOR & DEGREE
High School
College
Bus. or Trade School
Professional School
 
Have you ever been convicted of a felony? NoYes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
Do you have a Driver's License? YesNo
What is your means of transportation to work?
Driver's License
Number
State of Issue
Operator Commercial (CDL) Chauffeur
Expiration Date
Have you had any accidents during the past three years? YesNo How many?
Have you had any moving violations during the past three years? YesNo How many?
Dispatch Only
Typing YesNo
WPM 		Personal Computer
YesNo PCMac
CAD Yes | DISPATCH Yes | EMD Yes SKILLS No | EXPERIENCE No | EMD No
Other
 Skills
Please list two references other than relatives or previous employers.
Name
 Name
Position
 Position
Company
 Company
Address
 Address
Telephone
 Telephone
State of Michigan Emergency Medical Services License Number
Renewal Date
American Heart Association ACLS Provider
Issue Date Renewal Date
American Heart Association Healthcare Provider
Issue Date Renewal Date
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional informatio necessary to describe your full qualifications for the specific position for which you are applying.
Military
Have you ever been in the Armed Forces? YesNo
Are you now a member of the National Guard? YesNo
Specialty
Date Entered Discharged Date
Work Experience Please list your work experience for the past five years beginning with your most recent job held. If your were self-employed, give for, name.
 
Name of Employer

Address

City

State

Zip

Phone Number
 Name of last Supervisor
 Employment Dates
From
To    		Pay or Salary
Start
Final
Reason for living (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of Employer

Address

City

State

Zip

Phone Number
 Name of last Supervisor
 Employment Dates
From
To    		Pay or Salary
Start
Final
Reason for living (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of Employer

Address

City

State

Zip

Phone Number
 Name of last Supervisor
 Employment Dates
From
To    		Pay or Salary
Start
Final
Reason for living (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of Employer

Address

City

State

Zip

Phone Number
 Name of last Supervisor
 Employment Dates
From
To    		Pay or Salary
Start
Final
Reason for living (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
May we contact your present employer? YesNo
Days available for interview?
Person to be Notified in Case of Emergency
Name
 Address
Telephone
 Relationship

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Hart Medical EMS (hereinafter called "the Company"), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Hart Medical EMS, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Chief /Deputy Chief/ Captain or Company designee of the Company. Both the undersigned and Hart Medical EMS may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of Ninety (90) days and may be extended due to unforeseen circumstances, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Employee File Check Sheet
Name
 License Level

Personnel Data
Employment Application
Drivers License               Exp Date
Social Security Card

Tax Forms
Employee    
Federal W4 State W4 Detroit W4 I-9
MI New Hire Form
Contractor    
Federal W9

EMS Credentials
Michigan EMS License              #:                Exp Date  
National Registry Card (If Applicable) Exp Date  
CPR (HCP) Card Exp Date  
ACLS Card Exp Date  
PALS Card Exp Date  
Emergency Driving Certificate  
CEVO VFIS MCOLES
Hazmat Certificate  
Awareness Operations Technician Haz-Whopper

Other Certifications
  Upload Certificates
NIMS: IS 100.a - Introduction to Incident Command (Required)
NIMS: IS 200.a - ICS for Single Resources and Initial Action Incidents (Required)
NIMS: IS 700.a - National Incident Management System (NIMS), An Introduction (Required)
NIMS: IS 800.b - National Response Framework, An Introduction (Required)
NIMS: IS 701.a - NIMS Multiagency Coordination System (MACS) Course (Optional)
NIMS: IS 704 - Communications and Information Management (Optional)
Non-Compete Clause
Applicant Name *
 Date